Case Reports in Nephrology (Jan 2019)

A Case of Rheumatoid Arthritis Presenting with Renal Thrombotic Microangiopathy Probably due to a Combination of Chronic Tacrolimus Arteriolopathy and Severe Hypertension

  • Fumika Honma,
  • Yoshihide Fujigaki,
  • Yoshikazu Nemoto,
  • Hirotoshi Kikuchi,
  • Michito Nagura,
  • Shigeyuki Arai,
  • Kenichi Ishizawa,
  • Osamu Yamazaki,
  • Yoshifuru Tamura,
  • Fukuo Kondo,
  • Ryuji Ohashi,
  • Shunya Uchida,
  • Shigeru Shibata

DOI
https://doi.org/10.1155/2019/3923190
Journal volume & issue
Vol. 2019

Abstract

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A 51-year-old woman with rheumatoid arthritis presented with mild hypertension 20 months after tacrolimus treatment and developing proteinuria 24 months after the treatment. Tacrolimus was discontinued 27 months after the treatment, followed by heavy proteinuria, accelerated hypertension, and deteriorating renal function without ocular fundus lesions as a clinical sign of malignant hypertension. Renal biopsy revealed malignant nephrosclerosis characterized by subacute and chronic thrombotic microangiopathy (TMA), involving small arteries, arterioles, and glomeruli. Focal segmental glomerulosclerosis, probably secondary to chronic TMA, was identified as a cause of heavy proteinuria. The zonal tubulointerstitial injury caused by subacute TMA may have mainly contributed to deteriorating renal function. The presence of nodular hyalinosis in arteriolar walls was indicative of tacrolimus-associated nephrotoxicity. Together with other antihypertensive drugs, administration of aliskiren stabilized renal function with reducing proteinuria. Owing to the preexisting proteinuria prior to severe hypertension and the complex renal histopathology, we postulated that chronic TMA, which was initially triggered by tacrolimus, was aggravated by severe hypertension, resulting in overt renal TMA.